Talk:Depot medroxyprogesterone acetate/Archive 1

NPOV flag removed

Whoever put it here was anonymous and apparently unrelated to the various anonymous posters below.

I've rewritten the article, particularly the sections about side effects. (Many women have severe negative side effects, many women don't, information is good but there's no need to crusade.) I think it's NPOV enough to justify removing the flag, so I have. —Bsktcase 23:06, 16 May 2005 (UTC)

Off-topic stuff

I am doing a projec do you still get regular Orgasms

I have heard that regular orgasms are still had.

I did have regular orgasms while on the Depo Shot. However, it was easier to climax after I quit taking the birth control shot. If you are taking the Depo Provera shot now, I strongly urge you to stop and use another form of birth control. I have had nothing but problems with bone loss and fractures, weight gain, depression, and headaches. Sex is better off the Depo Provera Shot.

I'm sorry to hear you have suffered like that. Those are common experiences when using Provera - you certainly were not imagining them - and with Depo-Provera you can be stuck with them until it is all out of your system, which will be at least 3 months after the last shot, and can be much longer.

There are actually many scientific papers showing the processes whereby Provera would be able to cause all of those problems in some people, whereas others may have no problems. It is no reflection either way on the individuals, although bad medics often give the impression that those who complain are just being a trouble, or being "neurotic". Certainly Depo-Provera is not a good idea for anyone who suffers from depression (or anxiety, or cannot cope well with personal loss) or bone-loss, or heart problems.

Where there is doubt, but Depo-Provera would be really useful, one idea is to try the tablet form first, and watch out carefully for side-effects, for a reasonable period. It would still take a time for the drug to be entirely gone, if there are problems, but at least the process can start as soon as one stops taking the tablets. --Bluegreen 6 July 2005 00:53 (UTC)

The orgasms while on Depo where nothing compared to when I quit taking it. I still had them, but it is much, MUCH easier and more gratifying to climax now. As far as health problems, I gained 30lbs in 1 year, and I have had joint pains in my hips and knees. I also had severe mood swings and hot flashes. I have not had a shot in 7 months and my hormones are still not back to normal and I have not become pregnant. I have not used any other form of birth control.

Benefits section & Side effects re-ordering

I have added a section on benefits which mainly is comparitive to oral contraceptive pills (eg no loss efficacy by bowel upset). Also added points re use post-natally and that in some women can temporarily delay subsequent fertility. These points made each section quite long, so I added in bullet-points marks.

The oral contraceptive page is slightly confusing in that it makes little distinction between combined (oestrogen+progesterone) and progesteron-only pills. I'll have a think about this as the comparison DepoProvera vs progesteron-only pill is more about delivery systems unlike Depoprovera vs combined-pill where there are oestrogenic side-effects to consider. David Ruben 28 June 2005 20:03 (UTC)

progestogen

"synthetic progestin" is terminology that is used all the time, but maybe "synthetic progestogen" is a better term in some situations. --JWSchmidt 5 July 2005 06:29 (UTC)

That is a good point, but in circumstances where progesterone is never involved, only progestins, doesn't "synthetic progestogens" invite confusion over just what is meant by "synthetic", perhaps implying that factory-made progesterone is meant to be included, since there isn't necessarily an implication of not being a perfect version? Which then leads to the question "isn't 'synthetic progestin' tautology?", since progestins are the synthetic progestogens. Or is it a useful emphasis, since far too few seem to understand or respect the difference, at least until they personally experience the side effects of the wrong thing...

Would "imitation", or "facsimile" (strangely considered solely the word for a fax machine on Wikipedia), or "simulacrum" (or "simulacra") be any better? I was thinking "analogue", but that's apparently "A structural derivative of a parent compound that often differs from it by a single element", and that isn't what most progestins are.--Bluegreen 6 July 2005 00:29 (UTC)

Chemical castration

According to Chemical castration, Depo Provera, a progestin, is the drug used today for chemical castration. It acts on the brain to inhibit hormones that stimulate the testicles to produce testosterone. Does anyone know anything about this? This article makes no mention of it. -- Ec5618 12:10, 2 November 2005 (UTC)

Take a look at this. --JWSchmidt 12:30, 2 November 2005 (UTC)

It's been a few months now, and the article still doesn't mention Depo Provera's alternate use in chemical castration. Could someone see to it, please? -- Ec5618 20:35, 1 July 2006 (UTC)

Needle phobia under Side-Effects ?

The issue of this method requiring an injection is probably major reason why people choose not to consider it. User:Clayboy sensibly removed needle phobia from section entitled "side effects", with edit comment: Side effects - "needle phobia" is not a side effect 4 January 2006. Below is a copy of our discussion from User:Clayboy talkpage:

• I agree that needle-phobia is not strictly a "side-effect", but it is in my professional experience seen by patients as a major negative in the cost-benefit discussion of this contraceptive option. The problem is perhaps more of the section title of "Side Effects", but I tried to keep the section headings consistant with other articles on contraception. This point surely does not warrent a separate section of its own, but it does need to be included somehow in the article. My preference is to re-insert the sentance (not bulleted if that seems more acceptable) for the fudged compromise I originally made. However, that is not to deny the validity of your edit comment, so I would welcome your thoughts first. davidruben 23:51, 3 January 2006 (UTC)
• Thanks for commenting. I certainly have no professional experience in this field, but I found the point oddly misplaced, perhaps especially as the first in the list. I tried to figure out a way to integrate the information into the existing prose, but I found no natural place for it. Since you know what you are doing, by all means feel free to revert my edit. Clayboy 00:20, 4 January 2006 (UTC)

I have therefore reinsert the issue about needles, but changed the section title to try and make more sense. David Ruben ^Talk 01:05, 8 January 2006 (UTC)

I think this is a good solution, thank you. Clayboy 08:23, 8 January 2006 (UTC)

Additional Information?

I know that Depo Provera has been pulled from the market in Canada and possibly other countries. I was hoping someone could look into this and perhaps add the information to the entry. Info about how other countries treat medications can sometimes be enlightening, especially with the FDA's notorious reputation. I would like to add this info myself, but I currently don't have the time to do it. If it's not done in the future, I may have time to add it! Any suggestions/comments? Vanessa kelly 10:16, 20 January 2006 (UTC)

Recently in Oct'05, General Practitioners in the UK were urged to offer more women long-term methods of contraception rather than just short-term contraceptive pills (i.e. Depo-Provera, IUD/IUS & progesterone implants). See BBC News report re the National Institute for Health and Clinical Excellence's Press release. David Ruben ^Talk 23:27, 21 January 2006 (UTC)

This article states nothing about depo provera specifically. I know that there are various injectable contraceptives, in addition to IUD and implants, that can help women use contraceptives without having to remember to take a pill everyday. While I appreciate the article, it does not answer my question. Vanessa kelly 03:52, 6 February 2006 (UTC)

Moved stopping periods to side effect

I think it's wrong to place the fact some women stop having their periods under a benefit. To many/most women this probably isn't a benefit, (more difficulty telling if you are pregnant, signifies a serious change in your cycle etc.) It is more NPOV to put it more generally under "side effects" and then keep in the brackets that some women may consider this as a benefit.

• I disagree with this, as depo provera is commonly prescribed as treatment for the disease endometriosis. successful treatment and management of this disease require periods to be stopped. In fact it surprises me that endometriosis is not mentioned here- depo is used for this far more than it's used to castrate people, which does get a mention. I think I will add a section as it's a very important use for this drug. LouiseCooke

• Whilst I agree many women often express initial concern or uncertainty over this effect, there is nothing innately beneficial about having periods (vs adequate hormonal axis) as the presence or shedding of endometrial lining gives no health enhancing effect to the woman (assuming no unopposed endometrial hyperplasia is occuring, accepting issue of reassurance not being pregnant and that planned pregnancy can later easily occur). However of those women who do then choose this method, my personal experience is, the main reasons given are roughly equally between problems with other methods, ease of use (not having to remember method each day) or absence of periods. Indeed when the idea was floated a few years ago that those women with absolutely no periods for a few years might require occassional courses of oestrogen to reduce risk of osteoporoisis, many women were distinctly unhappy at the thought of having to manage the nuisance of a period again.
• I wont immediately revert back, but aside from what may or may not be a general benefit vs side-effect to the average woman, there is a clear indication for its use in those women who already have excessively heavy periods (menorrhagia) - see Menorrhagia#Treatment. Would a solution to this conundrum be relevent inclusion in both Benefits and side-effect sections? David Ruben ^Talk 14:32, 13 March 2006 (UTC)

Proposed Infobox for individual birth control method articles

Let's all work on reaching a consensus for a new infobox to be placed on each individual birth control method's article. I've created one to start with on the Wikipedia Proposed Infoboxes page, so go check it out and get involved in the process. MamaGeek (Talk/Contrib) 12:25, 14 June 2006 (UTC)

JUST DONT USE IT

--Peanut111 19:50, 14 July 2006 (UTC)This is just to warn those who are considering using depo provera. Dont. Although there may be some lucky women who have had no negative side effects, belive me, if you are the one who gets them, it will be life changing for you. I took the depo shot a few years ago, after my physician SWORE there was no chance of weight gain or other negative side effects.

At the time, i was about 35 years old. I only took 2 shots, 3 months apart. All my life prior to that, i had never been over 140 lbs. Within 10 months of taking depo, i gained 50 pounds! no, i am not exaggerating. Also, i had pain in my breasts every day. My asthma became worse, maybe from the Depo, maybe from the weight gain it caused. My period stopped, as the doctor had said it would.(personally, i think losing your period is always a bad sign unless youre pregnant) However, after i stopped taking the Depo, my period did not return. This is the one thing that they do not warn you about. The Depo WILL stay in your system almost indefinitely. A year passed after i stopped taking the depo, still no period! i was alarmed. i called my doctor. They told me "sometimes it takes longer in some people" !!!! Oh my god. So i waited, months passed. Still no period. After reading some articles on the web about this problem, I did what was suggested, try a fast to get the Depot out of my system. After day 2 of a fast- Bam! there is my period- full blown, not just a trickle. I have never been so releived or so happy to see my period. Despite all efforts, I still have not been able to lose any of the weight that i gained during that time, and i am 40 now.

I'm glad to see that Canada is banning this product or at least considering doing it. It is very dangerous. I am also so dismayed that so many doctors and the FDA are totally complacent and blind to the real dangers in so many pharmaceuticals.

Whilst personal bad experience is unfortunate and to be regreted, this fails constitute an overall assessment for a drug (anyone having a potential life-threatening allergic reaction to a penicillin antibiotic can reasonably view that drug as harmful, but this is fortunately relative uncommon and a far greater number of patients have benefit from penicillin antibiotics). There is no inherrent reason why having periods is beneficial (other than reassurance not being pregnant), the only reason why combined pill runs with a 4 week cycle (the bleeds are not strictly periods but withdrawal bleeds on withdrawing the hormomnes during the pill-free week) was as a marketing ploy when the combined pill was first introduced: to make it seem more "natural" and thus acceptable. Many women who are greatly troubled with excessively heavy or painful periods are advised to take their combined pills continuously (without a gap) for upto 3 months at a time (unlike progesterone Depo-provera, the oestrogen content of combined pills over a more prolonged time might increase the risk of hyperplasia and thus endometrial cancers). However as you correctly point out, weight gain is possible (but likewise on the progesterone-only pill) but less commonly seen that with combined contraceptive pills (of which max gain I have encountered was 70 pounds). Depo will not stay in the system indefinitely - it is mostly absorbed from the fat tissues (where injected) and broken down over about 3 months, although low levels may persist for a few months more - however the resumption of the normal cyclic hypothalamic-ovarian hormone axis may take some time after this (generally no longer than 6-9 months, but remember for most women normal periods will return much quicker than this). Typically average times to conceive after stopping Depo-provera are about 6-9 months (some as quick as 1 week and other women longer). Depo-provera does not have indefinite perminant affect on weight: I agree loosing gained weight is hard, but equally so does every other person who has found they have gained weight - if being overweight is really something atypical to ones metabolism, one might wonder if some other condition has coincidentally occured (e.g. under active thyroid). Yes concerns have been raised for longterm effects of lower ostrogen levels (re osteoporosis), but suitable high impact exercise, calcium intke and limited years of use may all help minimise this (although not eliminate entirely) - against that compare with combined contraceptive pill which also has risks (DVTs, PEs, strokes, cardiac disease, breast cancer). So no method of contraception is without potential health risks (except perhaps absinance - but that has relationship risk !). Recent UK doctors were officially criticised for not making better use of longterm methods (Depo-provera and IUDs) vs just offering combined pill prescriptions - so yes have problems and good knowledge of this important. Of course even more important is that doctors/nurses properly counsel women over the pros & cons of the full range of contraceptive options. David Ruben ^Talk 23:29, 14 July 2006 (UTC)

Response to the don't use it.

I think that the Depo shot is great. I used the pill prior to the Depo shot, and ended up pregnant with my daughter. After my daughter I got on the Depo shot. I only had a period once every three months, but I was not complaining about it. That was the only side effect that I had. I did not gain any weight, or anything else. I was on the shot for 4 years. And when I decided to stop the shot, it was because I wanted to get pregnant. I was pregnant with my second child with in 2 months. Yes, some consider me to be lucky because for most it takes longer. However, just because you had a bad experience, does not mean that they will, everyone is different. I believe that you should just continue to exercise while you are on it, and you will be fine. And by the way, I am on it again.

—The preceding unsigned comment was added by 69.154.180.135 (talk • contribs) . 22:07, 16 July 2006

I'm with you. Not having periods is great! It is definitely NOT a negative side effect. I used to have to stay home in bed at least one day every single month, the pain and vomiting were so bad. I gained some weight, but I used to be a size 0-2 (ridiculously tiny for an adult), so that was fine by me. (I am now at size 6-8, or a smallish medium--normal, in other words). I would never let one person's bad experience convince me that no one should use it. I have been using it since early 1997, and have not developed any new health problems I didn't have prior to that. In fact, the article mention the possibility of UTIs as a negative side effect, and my occurence of them actually went *down*. This article in general strikes me as very anti-DMPA, and not very objective at all. It reads more as a warning against DMPA than as an article on a very normal, widely-used medical product/procedure. Emily-—The preceding unsigned comment was added by 24.131.12.228 (talk • contribs) 02:12, 2 October 2006.

Agree.

68.255.20.88 08:05, 3 November 2006 (UTC)

who/unfpa

http://www.mindfully.org/Reform/2002/Bush-Antichoice-WHO-Funds31oct02.htm

maybe you're uninformed, maybe you didn't read carefully--i dunno. but who and unfpa are the same thing. maybe you should also inform yourself re nssm 200--the declassified (as of 1989) document regarding population control and us aid to developing countries.

also crucial to note that the who didn't "review" any new evidence, and they do not claim that depo doesn't increase the risk of breast cancer or cause bone density loss--i.e., they don't have an alternate opinion on the safety of depo. they don't mind if its dangerous to women as long as it works to prevent pregnancy. Cindery 04:23, 14 August 2006 (UTC)

The POV portion of your sentence was, specifically:

The WHO, however, has ties to US AID, the World Bank, and population control groups which have systematically advocated global campaigns for the use of contraceptives in developing countries for political reasons, such as maintaining the economic interests of wealthy countries.

Some women's advocacy groups believe that the June 2005 expert consultation convened by the World Health Organization (WHO) to assess current evidence on the relationship between hormonal contraceptives and bone health, which noted the particularly important role played by Depo-Provera in regions where maternal morbidity and mortality are high, understated Depo-Provera's risk of causing bone loss when they issued their July 2005 statement recommending no restriction on use of, or duration of use of Depo-Provera.[1] This was different from the November 2004 recommendations of the FDA [2] in the US and the CSM [3] in the UK which warned against using Depo-Provera for longer than two years unless other birth control methods were inadequate for a woman.

The WHO department that issued the statement, the Human Reproduction Programme (hrp),[4] was launched in 1972 as global program of technical cooperation by the WHO, UNFPA, UNDP and World Bank to promote, coordinate, support, conduct and evaluate research on human reproduction with special reference to the needs of developing countries. Advocacy groups distrust the WHO/hrp recommendations, citing past USAID funding UNFPA distribution of Depo-Provera in other countries where it was approved for contraceptive use before the FDA in 1992 expanded its indications to include contraception. [5] The FDA had twice (in 1978 and 1983), contrary to its own advisory committee's recommendations, failed to approve Depo-Provera for use as a contraceptive, because a FDA requirement in place from 1969 to 1989 mandated that steroid drugs be tested in beagles, [6] and Depo-Provera was found to cause mammary tumors in beagles after they received the equivalent of 25 times the human contraceptive dose for over three years. [7]

68.253.213.24 19:21, 14 August 2006 (UTC)

i was responding to your summary deletion without discussion of ehrenreich as a reference, which you justified by saying that her article didn't mention the WHO.

regarding political pov, i am planning to add a controversy section for depo, regarding the long history of scientific, social, and political concern by many people that it is not a safe drug. there is a lot to cite from reliable sources.

the larger issue of the WHO--is it humanitarian viz birth control or just interested in depopulation by any means necessary? may be too big of a subject to cover here, but it's not a controversy i invented/may bear mention viz the history of depo, since it weas used so widely in third world with US money when the US wouldn't approve it for safety reasons, via USAID/IPPF/WHO/UNFPA, etc. the big problem poeple have with WHO is that it gets so much money from the USAID, which demands that funds spent on any other form of aid (food, medicine) be contingent upon use of birth control--which is coercive. also that they target "overpopulated" developing countries for this coercive birth control "aid," not developed countries, with the cheapest/least safe/most likely to require medical care which is not available forms of birth control. entire countries in the third world are suspicious of the WHO--the country of nigeria refused a WHO polio vaccine because they feared it was intentionally contaminated with sterilization drugs. the catholic women's league of the phillipines successfully got a court order to halt the distribution of a WHO tetanus vaccine contaminated with hgc. (the WHO claimed ignorance, then that the hgc was too weak to terminate pregnancies or cause sterlization. but they spent 53? million dollars trying to develop an anti-pregnancy vaccine that could attach to tetanus vaccine, a fact which was documented in the Lancet...) this vaccine was used in developing countries, and only on women of repoductive age. Cindery 21:10, 14 August 2006 (UTC)

re weight gain "possible"

http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?id=475

weight gain is common/likely with depo, not merely possible. Cindery 09:42, 14 August 2006 (UTC)

depo and ovarian cancer

i'm seeing weak substantiation for possible protective effect for endometrial on pubmed, but not ovarian. (there is also the monkey study in which depo is associated with occurrence of endometrial carcinoma.) depo seems to be used as adjunctive, palliative treatment for progersterone-receptor-only endeometrial carcinoma for patients who are too sick for surgery, or want to preserve fertility--with mixed effect. i'm not sure reduced risk of endometrial is really a benefit which can be claimed for depo, as the basis is speculative/based on reduction of exposure to estrogen, which is correlated with higher risk for endometrial carcinoma. (smoking also reduces exposure to estrogen and hence smokers have lesser risk for endometrial carcinoma...but we would hardly claim this as a "benefit" of smoking...)

PMID 8200214

antibiotic interaction viz oral contraceptives

i am removing the claim as a benefit for depo that its efficacy is not decreased by antibiotics, as pill efficacy (with exception of rifampin) is not decreased by them either. "does not interact with rifampin" a rather far-fetched benefit...

PMID 12063491 Cindery 12:58, 14 August 2006 (UTC)

Notwithstanding that (PMID 12063491) meta-analysis of June 2002, this remains at odds with current UK standard advice (UK Family Planning Association). As per British National Formulary advice for COCP: "Some broad-spectrum antibiotics (e.g. ampicillin, doxycycline) may reduce the efficacy of combined oral contraceptives by impairing the bactrerial flora responsible for recycling of ethinyloestradiol from the large bowel. FPA advice is that additional contraceptive precautions should be taken whilst taking a short course of a broad spectrum antibiotic and for 7 days after stopping ..... If the antibiotic course exceeds 3 weeks, the bacterial flora develops antibiotic resistance and additional precautions become unnecessary; additional precautions are also uncessary if a woman starting a combined oral contraceptive has been on a course of antibiotics for 3 weeks or more" (BNF 45 March 2003). You are of course correct with there being additional warning re enzyme inducers (such as rifampicin but also carbamazepine, phenytoin etc etc) that have an effect mediated by the liver which affects both COCP & POP, indeed "Rifampicin & rifabutin are such potent enzyme-inducing drugs that an alternative method of contraception (such as an IUD) is always recomended" (BNF 45)

The concern is less with whether broad-spectrum antibiotics affects all women as to whether it may affect some women, which is unknowable in advance. As a differe4nt metanalysis (PMID 11704183) concludes: "Pharmacokinetic studies of other antibiotics have not shown any systematic interaction between antibiotics and OC steroids. However, individual patients do show large decreases in the plasma concentrations of ethinyl estradiol when they take certain other antibiotics, notably tetracycline and penicillin derivatives. Because it is not possible to identify these women in advance, a cautious approach is advised." A later paper in Oct 02 (PMID 12436822) whilst noting the lack of evidence, notes "experts on this topic still recommend informing oral contraceptive users of the potential for a rare interaction"

Finally the current FPA webpage continues the same advice (see http://www.fpa.org.uk/guide/contracep/compill.htm#17) so this remains, for now, the consensus medical opinion (remember wikipedia is not about trying to research the "truth" but accurately reflect current knowledge, even if this is imperfect).

For these reasons, I am restoring the stated advantage of being unaffected by broad-spectrum antibiotics - an explanatory footnote seems appropriate though to expand on the discrepancy in official advice and research. Also the lack of problem with any oral medication in patients with malabsorption conditions was also removed and restored. David Ruben ^Talk 22:36, 14 August 2006 (UTC)

POV pushing ?

Cindery - please review your subsequent edits - I feel this is POV pushing - as Wikipedia reports on accepted wisdom, not to argue out how this is wrong and should be changed. It is not that any specific point is wrong, but more the wording or the emphasis being given. Hence:

• Re lack effect with antibiotics - warnings for effect of antibiotics and COCP are in BNF and form part of FPA guidance - this is de facto official advice in UK and as such should be what wikipedia reports. Cases where this may be pertinant are for women with acne needing repeated pulse courses of antibiotics - the FDA whilst offereing the standard advice re need extra precautions each time antibiotics started, advised me to suggest use of Depo-provera or IUD as alternatives in such cases. The research may indeed be lacking, but this is accepted clinical practice and I have well cited this as being the case.
• Re effects on of ovarian, liver or cervical cancers - notice I had used the phrase "It is not thought ..." and provided a citation for this Br J Fam Plann " Position paper" opinion (PMID 10454658). Other studies may or may not support all aspects of this assessment, but one study/paper does not make clinical consensus.
• re "This study also noted that "children with DMPA exposure during pregnancy and lactation had an increased risk of suboptimal growth in height," but that "after adjustment for socioeconomic factors by multiple logistic regression, there was no increased risk of impaired growth among the DMPA-exposed children." " is superfluous - if after appropriate elimination of confounding biases (not sure that's quite the correct choice of term) no effect seen, then surely no need to qualify the conclusion that it does "not adversely affect the long-term growth"
• To state "At least one of the authors of the study, AZ Lacroix, is a consultant for Pfizer." and then discuss the institution receiving financial support, is to imply a personal assessment of the conflict of interests and thus validity of the paper and its findings - wikipedia is not the place to argue out such assessments (WP:No original research), unless a WP:Reliable sources voices that opinion and thus can be cited.David Ruben ^Talk 00:01, 15 August 2006 (UTC)

re lacroix

no conclusion is made, her association with pfizer is merely noted, and from a reliable source. readers can make their own conclusions--that's why it is ethical per the standards of the profession to disclose and note conflicts of interest. i.e., a journal may publish a study, but it also notes the conflict of interest, so readers can take that into account--the study is not considererd unpublishable, etc. wikipedia need not be any different (especially since this claim re bmd return only comes from one study--an effect which has been reproduced nowhere else-- and is given so much weight in the article.) POV pusing would be the opposite--NOT citing the conflict of interest. Cindery 00:11, 15 August 2006 (UTC)

But emphasising the disclosed conflict of interest for this, vs all citations given across wikipedia, is being selective and POV ? The articles themsleves, if from reputable peer-reviewed journal, should be disclosing any possible conflict of interest (thus, it is hoped, showing that the author is being open and not trying to be biased). Likewise problems of methodology should generally not, I believe, be commented in the wikipedia article, the citation link is there for the reader to look at the original article and assess the overall methodology, results and conclusions drawn. David Ruben ^Talk 00:27, 15 August 2006 (UTC)

when something sounds to good to be true, i check up on it. for medical journal articles with effusive claims about a drug or safety claims not repoduced elsewhere, what i usually find is a financial connection between one or more of the authors and the drug company. (or financial sponsorship of the study/institution itself, or a link to the NIH. lacroix study was paid for by the NIH, by the way, which is swimming in drug company money--but i left that out because explaining the lack of objectivity at the NIH seemed like to big/complicated of an issue to address here.) lacrox disclosed her pfizer conflict of interest for a medical journal which required disclosure, and i provided the link. sadly for readers, full texts of the lacroix depo-bmd studies are not available online for free, only the abstracts, so readers cannot "go to the original article." i am not personally able to check on conflicts of interest for all articles cited across wikipedia, but it is something i try to do for every article to which i contribute, as you know. i am not really inspired to check up on articles--even if the findings support a drug i do not support--unless there are red flags. as i mentioned, the red flags are effusive/nonscientific claims and/or improbable-sounding safety claims from only one source. Cindery 01:09, 15 August 2006 (UTC)

re antibiotics

i'm opposed to selective comparative benefits (but complete listing of comparative advantages/disadvantages would be unwieldy). hence, the selected advantages/disadvantages should be of note. the known noninteraction of depo with rifampin does not appear notable (or exclusive to depo). barrier methods, which do not interact with antibiotics, do not claim this as a benefit, for example. given the sketchy status of anitbiotic interaction with ocs, and the number of other bc methods with do not interact with antibiotics, it seems like a pushing of depo/strecthing pretty far to find dubious benefits for it. Cindery 00:11, 15 August 2006 (UTC)

suboptimal height

not superfluous at all--the socioeconomic factors surrounding depo use are of crucial importance, esp. given pfizer's subsidized title x "buy one get one free" to low-income clinics, and mass use in developing countries. there's also the possibility that "socioeconomic" factors have nothing to with it--the fact is, the study found suboptimal height and then speculated via math. "socioeconomic factors" may ot may not cause the suboptimal height found in depo-exposed children. either way, it's significant. Cindery 00:19, 15 August 2006 (UTC)

All (well virtually all) studies need to use controls and statistical methods to eliminate or quantify bias (otherwise there goes the whole of field of Medical Statistics). The study concluded no overall effect and this is the opinion that citing this source should be verifying. Again lengthy quoting of explanatory findings and interpretation seems, to me, out of place in wikipedia (as being actually debating vs reporting of a debate), and the role of the citation link is to allow the reader to lookup the methodology, results and full conclusions. In part this is question of encylopedic style - we could include dozens of pages I am sure of FDA submissions over any given point/reported side effect, but this would not make for good editorial encyclopaedic writing :-) David Ruben ^Talk 00:44, 15 August 2006 (UTC)

i think this is all sort of beside the point--pregnancy is very uncommon with depo, and pfizer concedes low birth weight/likely death fo any children conceived. but things *don't* look so good for the ones who are... "multiple logistical regression for socioeconomic factors" is highly speculative-- and socioeconomic factors such as less access to high quality food and/or medical care (if we presume that's what they mean) are very relevant to depo use, as people with "socioeconomic factors" are most likely to use it. suboptimal height is significant because first they found it, then they ran numbers based on factors not defined in the abstract to render the finding irrelevant.

i think part of the problem may be mixing up pregnancy and breastfeeding, from the point of origin of breastfeeding on depo as a depo advantage. as with mirena, there should be separate section for depo and pregnancy/depo and breastfeeding. and that depo and breastfeeding should not be listed as an advantage, but under "Depo and breastfeeding." Cindery 01:27, 15 August 2006 (UTC)

re ovarian/liver cancer

that is superfluous--we do not, for example, see in every drug article whether or not the drug is associated with ovarian and liver cancer. what is notable is whether it increases or decreases risk. if it has no effect, that's superfluous information.

Fair point. However if there is particular public (media) concern over say COCP effect on a specific cancer (for sake of this discussion, whether or not true), then may well be of importance for women who wish to start contraception, to choose method not associated with such a risk. This may be more relevant for process of clinical setting and guidelines on advising women of pros/cons of various options, rather than "encyclopaedic" information I suppose. David Ruben ^Talk 00:44, 15 August 2006 (UTC)

Also if many other methods are associated with some small risk of an additional cancer and one particular method is not, that may in itself make it a notable point (i.e. the contrast to other methods) David Ruben ^Talk 00:51, 15 August 2006 (UTC)

the obvious answer to that is--why not put a notice on all the articles for hormonal bc which says, by the way, if you'd like to completely avoid the risk of cancer with birth control, and your head is spinning from "comparison shopping for cancer risk" based on a bunch of shify and ever-shifting dubious studies from drug companies and population orgs about what the risks are, you could get a diaphragm and pay attention to when you're fertile--will save you so much time from worrying or suffering from side effects or disease it's actually more convenient, in additon to being inestimably safer.

that said, always comparing risks between hormonal methods but never comparing risks between hormonal and barrier methods does seem odd...and i don't think it's relevant to note "no effect on risk" for any cancer as an implied comparison between two methods of bc. Cindery 09:07, 15 August 2006 (UTC)

re cervical cancer

pfizer itself notes this as a risk in the product insert. (the WHO seems to have tried to bury the cost rica study findings of increased risk of cervical cancer by limiting their review to *invasive squamous cell cervical cancer* only, so that people will read it and think cervical cancer is not a risk with depo, when in fact cervical cancer with depo is merely less likely to be invasive. pfizer knows the risk of cervical cancer is there-- that's why they left the warning on the product insert--they don't want to be sued for failure to disclose.) Cindery 00:37, 15 August 2006 (UTC)

your uk position paper

is exactly that-- a position paper, and a heavily pov one, which might even be called misogynist. it makes a lot of unsupported refs to "bad publicity" for depo in "women's magazines"--as if scientific concern over the safety of depo were not well-established, but merely supersitious b.s. with the gravity of puffpieces about lipgloss. it also cites no references whatsoever. Cindery 00:30, 15 August 2006 (UTC)

privacy

i am seeing privacy listed all over the place as a possible benefit of depo. i suppose that for women who would like to conceal the fact that they are using birth control from their parents or sexual partner(s), the lack of material evidence--pill case, diaphragm case, etc--might be a benefit. (how to conceal any severe side effects, though? a trip to the emergency room or bleeding nonstop could sure ruin the privacy aspect...) still, in interest of fairmindedness, privacy seems to be a possible benefit, unique to injectables. Cindery

mess i have made of references in controversy section

sorry for being so lame. see"6" should now say see"8." here is the link: http://www.multinationalmonitor.org/hyper/issues/1985/02/problems-us.html

the quote you are looking to verify re they are "in the population control business" is at the bottom, in a section about "who are the experts?" the speaker is dr. j crout, former head of fda bureau of drugs.

perhaps it is also useful to mention that the author is amy goodman. she wrote a thesis for harvard on depo provera, and it was published as a series of articles in the multinational monitor and the boston globe in 1985. a list of chapters/sections is here: http://www.multinationalmonitor.org/hyper/issues/1985/02/index.html Cindery 20:46, 16 August 2006 (UTC)

No it should not say "see"8."" - a link is required not a self-referential remark about wikipedia. In line links are, I believe, poor style of giving citation and make a real mess to an article that is using the more expansive cite.php ref-tagged system.... there I've had my grumble :-) David Ruben ^Talk 01:57, 17 August 2006 (UTC)

..well, when i said "mess" i did mean not just screwing up the inline citations but making them in the first place instead of learning how to properly footnote! :-) i concede the point entirely that i am technically incompetent--and also that it is no excuse. (but at least when i cite in line the links work--when i try to use footnotes i just leave nonsensical hieroglyphs all over the page that link to nothing, which is probably more irritating?) but, thanks for working up way more than your fair share of refs. feel free to leave "the idiot's guide to wiki footnotes" on my talk page--the standard guide is not appropriate in my case, i'm afraid. Cindery 06:07, 17 August 2006 (UTC)

disappearing link

the link to the popline document (controversy section, referring to FDA official transcript of proceedings/evaluation of the value of upjohn's studies) seems only to last 24hrs, twice now--it may automatically expire every day? if so, i'm not sure what to do about it--scan somehow and store? provide document # and link to popline database? provide full text(below) as addendum? (i think that would take up too much space...) Cindery 23:38, 17 August 2006 (UTC)

1. Title: [Testimony]. Author: Annello C Source: In: United States. Food and Drug Administration. Depo-Provera Public Board on Inquiry. Official transcript of proceedings, Food and Drug Administration. Depo-Provera Public Board of Inquiry. Vol. 5. January 14, 1983. Arlington, Virginia, TIW Reporting Group, [1983]. :26-31. Abstract: An attempt is made in this congressional testimony to evaluatethe quality of the human epidemiological studies of Depo-Provera and to draw some conclusions about cancer risk in humans from the currently available studies. When assessing the quality of the epidemiological information, design, execution, and analysis of the data are considered. The quality of information on exposure and cases or disease, potential confounding factors, the duration of exposure, length of follow-up, the completeness of follow-up and cohort studies, the method of handling confounding factors, the appropriateness fo the comparison group, the statistical power when hypothesis testing is under consideration, and confidence intervals, when the issue is relativeto estimate, all require particular attention. Generally these criteria relate to 2 issues: bias and sampling variation. In epidemiologic studies, the potential for bias is very large and important. Overall, the epidemiologic studies considered -- studies by Greenspan, Ory, Lian, the 3 Grady studies, and 2 studies based on Thai data by McDaniel -- are of questionable or poor quality. The 3 studies at the Grady Memorial Family Planning Clinic are based on information which was derived for purposes other than studing cancer. The Food and Drug Administration (FDA) report raised some serious questions about the quality of patient follow-up and the medical information available for conducting scientific investigations. There are difficulties with the design and execution of each of the Grady studies which limit their usefulness. The significant problem for the Greenspan study is the appropriateness of the comparison group and to a lesser extent the issue of statistical power. The problem with the Lian study is the completeness of the follow-up. The 2 McDaniel studies are very poor for drawing inferences about the possible relationship between Depo-Provera and cancer. With regard to the inferences that can be drawn from these epidemiological studies, overall the epidemiologic evidence made available for review was inadequate to draw meaningful conclusions. The carcinoma in situ observation from the Upjohn NDA and the breast cancer observation emerging from the mental retardation hospitals in Ontario, Canada, represent unexplained observations that have neither been confirmed nor refuted. The 2 papers from Thailand did not enable the drawing of inferences with regard to the association of Depo-Provera and cancer. In sum, there has not been any data which allowed the drawing of meaningful conclusions about the relationship between carcinogenicity and Depo-Provera. With rigorous attention to detail and follow-up, the approximately 10,000 exposed women at Grady Memorial Family Planning Clinic might provide a large enough data base to obtain some interpretable US information on the cancer issue. Language: English

Document Number: 025995

net en

i removed references to net en because we don't need to know about other injectables to understand mechanism of action of depo. (also because there's no wiki page for net en, and it isn't explained/discussed anywhere else in depo article--mentioning it is just confusing for readers who don't know what net en is). Cindery 17:59, 30 August 2006 (UTC)

herpes in mice

the statement is phrased condionally to reflect the conclusions of the authors of the study that because depo does increase susceptibility/decrease immune response to herpes in mice they extrapolate the possibility to humans (based in part on their previous research in hormones/human female immune response).

"native american"

the article by sara littlecrow is a publication of the well-regarded pop-dev program at hampshire college. littlecrow clearly states that there is no established link between enhanced hiv transmission and humans, and notes the monkey studies which have caused concern in footnote below:

11. Marx, P., Spira, A., Gettie, A., Dailey, P., Veazey, R., Lackner, A., Mahoney, C., Miller, C., Claypool, L., Ho, D., & Alexander, N. Progesterone Implants Enhance SIV Vaginal Transmission & Early Virus Load Nature Medicine Vol.2 No.10 October 1996.

the monkey studies, incidentally are of concern to a number of writers/this can be found in a number of places, i.e., not just her opinion, but part of her research.

i have no idea why you would note her racial or ethnic identity in the article, unless you mean to imply that "native american health care activist" is a derogatory term/implies that she is not qualified to write articles for academic organizations (they seem not to agree with you). Cindery 19:54, 4 September 2006 (UTC)

"woman"

i would say the burden is on you to research the subject and prove that it is only her opinion (especially as she cites a study, and the same study is cited in the herpes study). i could go and add several refs to the one that is already there, but the google search is your job if you want to claim that it is only her opinion. Cindery 20:52, 4 September 2006 (UTC)

Long quote

I'd propose reverting to the August 30th version. I understand that two of the disadvantages were disputed by 68.253..., but I do not agree with the solution to this conflict (i.e. filling the article with a large quote). The previous version was fine. It made a concise statement, and it was supported with a citation. I like how this section was previously a bulleted list of points with fairly short sentences/statements describing each point. If I am viewing the page history correctly, it seems 68.253... cherry picked a quote to purposely shed doubt on the statement (that was already cast speculativly, saying "may" instead of "does"), and then Cindery added even more of the quote to contextualize it, and highlight other points, when in actuality, the page, in my personal opinion, was better before any of the quotes were introduced (writing so much on such a small point is giving it undue weight when compared with the other points listed). Maybe a compromise still needs to be worked out, such as moving some of the controversial points to a controversies section (that is if they are actually controversial in cited sources, not controversial to 68.253... personally). But for the time being, would both editors support reverting to an earlier version and trying to work things out on talk?--Andrew c 21:57, 5 September 2006 (UTC)

endometrial cancer

Removed clinically irrelevant, intentionally misleading and deceptive statement:

(In monkey studies, however, Depo is associated with a higher risk for endometrial cancer.)

• Data on DMPA have shown a number of noncontraceptive and therapeutic benefits, the most prominent of which is an 80% reduction in the risk of endometrial cancer. PMID 11727175

• The relative risk of endometrial cancer was estimated to be 0.21 in women who had ever used DMPA. The reduction in risk of endometrial cancer is at least as great for DMPA as for combined oral contraceptives. PMID 1831802

• In one unpublished 10-year study of DMPA begun in 1968 at the International Research and Development Corporation (IDRC) of 52 female Rhesus monkeys (4 controls + 3 groups of 16 receiving the equivalent of 1, 10, and 50 times the human contraceptive dose), 2 monkeys in the highest dose group (equivalent to 50 times the human dose) developed endometrial cancer. PMID 8200213

• After reviewing proposed guidelines from a February 1987 WHO symposium to change safety testing of contraceptive steroids to reflect current scientific opinion, in November 1987 the FDA revised its nonclinical (animal) testing requirements for contraceptive steroids, eliminating the requirement for long-term testing in monkeys (that had been in place for over 19 years) because it did not predict carcinogenicity in humans. PMID 1493710

68.253.189.62 18:55, 6 October 2006 (UTC)

Disadvantages and side effects WP:NOR violations

The first sentence of this article says it is about the contraceptive Depo-Provera. The article contains a section entitled Disadvantages and side effects. This section lists two new "disadvantages and side effects" that have never before been listed as disadvantages or side effects for women using Depo-Provera as a contraceptive in any reliable source:

1. Depo Provera may simultaneously increase susceptibility to the herpesvirus and decrease immune response to the herpesvirus. PMID 12663762
2. Depo Provera exacerbates glutamate excitotoxicity, which may render users more vulnerable to "neurodegenerative insult"--a greater likelihood of such diseases as fibromyalgia. PMID 16864144

• The first statement cites a single study comparing the susceptibility of inbred mice to HSV-2 after pretreatment with subcutaneous Depo-Provera versus pretreatment with subcutaneous progesterone.
• The second statement cites a single in vitro study of glutamate excitoxicity of embryonic rat hippocampal neurons treated with Depo-Provera (incidentally, the reference never mentions fibromyalgia).

WP:NOR prohibits "any unpublished analysis or synthesis of published arguments, ideas, data, or theories that serves to advance a position." Doing a Pubmed search on "Depo-Provera", finding abstracts of one study of inbred mice and one study of rat neurons in cell culture and proposing they "may" be two new disadvantages and side effects for women using Depo-Provera as a contraceptive constitutes original research. Citing published sources to advance a position is still original research and violates Wikipedia policy. 69.208.178.182 23:49, 2 November 2006 (UTC)

You make a very good case.I believe Cindery added that info, so I will contact her and invite her to comment here.--Andrew c 00:23, 3 November 2006 (UTC)

this isn't an OR issue, it's a primary source issue. Wikipedia is clear on primary source being preferable to secondary sources in the case of sci/med. The pubmed citations are primary source citations--exactly where and what they should be. Regurgitating the canned list of advantages/disadvantages from websites is not preferable--they are lame, inadequate, uninformative-- an argument in favor of Wikipedia's policy on primary sources and sci/med. Re "advance a position"--you would have a hard time making the case that any position is being advanced other than the tedious and altruistic task of editing the encyclopedia for the benefit of readers...please remember to "assume good faith." Thanks-- Cindery 01:46, 3 November 2006 (UTC)

Because not many people watch this page, and because this seems to me to be policy points, I have requested comments here from WP:RS, WP:OR and Wikipedia:WikiProject Medicine. Hopefully, we will have more imput soon.--Andrew c 03:33, 3 November 2006 (UTC)

"Wikipedia is clear on primary source being preferable to secondary sources in the case of sci/med"? What? Where??

From WP:NOR, 2.2 Primary, secondary, and tertiary sources:

• Secondary sources are documents or people that summarize other material, usually primary source material. Wikipedia articles should rely on reliable, published secondary sources wherever possible. This means that we publish the opinions of reliable authors, and not the opinions of Wikipedians who have read the primary source material for themselves.

Although most articles should rely predominantly on secondary sources, there are rare occasions when they may rely entirely on primary sources. An article or section of an article that relies on primary source should (1) only make descriptive claims the accuracy of which is easily verifiable by any reasonable adult without specialist knowledge, and (2) make no analytic, synthetic, interpretive, explanatory, or evaluative claims. Contributors drawing on entirely primary sources should be careful to comply with both conditions.

From WP:RS, 10.2.1 Cite peer-reviewed scientific publications and check community consensus:

Honesty and the policies of neutrality and No original research demand that we present the prevailing "scientific consensus". Polling a group of experts in the field wouldn't be practical for many editors but fortunately there is an easier way. The scientific consensus can be found in recent, authoritative review articles or textbooks and some forms of monographs.

1. I propose basing information in the Disadvantages & side effects section on secondary sources such as: (1) recent, authoritative review articles on Depo-Provera as a contraceptive in peer-reviewed journals, (2) chapters on Depo-Provera in recent medical reference textbooks on contraception, and (3) sections on Depo-Provera in chapters on contraception from recent major medical textbooks of endocrinology, gynecology, internal medicine, and pharmacology.
2. I propose not basing information in the Disadvantages & side effects section on a Wikipedia editor's interpretation and opinion of the significance for women using Depo-Provera as a contraceptive of primary source basic science studies comparing the susceptibility of inbred mice to HSV-2 after pretreatment with subcutaneous Depo-Provera versus pretreatment with subcutaneous progesterone and examination of the glutamate excitoxicity of embryonic rat hippocampal neurons in cell culture treated with Depo-Provera.

69.208.178.182 05:19, 3 November 2006 (UTC)

Except you left out the parts below. (Specifically the injunction: "cite his published papers.") As you are probably aware, there is likely to be no opinion given on the latest research on the disadvantages of Depo Provera in Cochrane's etc--no opinion doesn't mean research on the disadvantages is not relevant/there will never be a Cochrane's opinion, it means there's a lag time, sometimes of years, before Cochrane's amasses enough studies on anything for epidemiological review. There is no "scientific consensus" on, say, glutamate excitotoxicity and MPA in cochrane's--but that doesn't mean citing the study contradicts a "scientific consensus,"--the current scientific consensus pertaining to glutamate toxicity/MPA is the cited pubmed study. (Per the idea of citing textbooks--the "scientific consensus" rules for Wikipedia were written largely to keep renegade physicists etc from publishing their own minority viewpoint theories--not to exclude current pubmed research.) Limiting every medical article in Wikipedia to using a single source--say, Cochrane's--is not a Wikipedia standard. In this case, I think it would be merely trying to exclude valid, cited info on a technicality that doesn't apply, and perhaps because you find it objectionable?--didn't we have this argument already? Were you the anon who almost went to 3RR over the herpes rat study, until I left the incredibly long quote, because you objected to how it was summarized, until Andrewc requested that the original summary be restored?)

All the possible disadvantages based on single studies are clearly stated in the conditional, without interpretation, and are properly cited. Every established disadvantage is not stated in conditional tense.) Pubmed citations are not only approved citations for Wikipedia med articles--Wikipedia has a tool called Diberri's specifically to easily format pubmed citations/auto-hypertext the citation numbers. Moreover, since Wikipedia is digital, it can include Oct 2006 NEJM citations, whereas medical textbooks must wait for new edition to be printed--that doesn't make citing 2006 pubmed "OR" in 2006 Wikipedia. Cindery 06:24, 3 November 2006 (UTC)

The anon 69.208.178.182's suggestion (2) appears reasonable (Note: I haven't looked at the article or its edit history, just the above comments). The jump from basic research in rat/in vitro to relevance in humans taking a medicine is a textbook example of why primary sources should be used with caution (excuse the pun). I'd like Cindery to point out the Wikipedia guideline that prefers primary sources over secondary ones (the popular press doesn't count as a secondary source wrt science research – more like a tertiary source, usually written by journalists with no science background, so the arguments below don't apply to textbook vs research paper.). User 69.208.178.182's suggestion (1) to just use only secondary sources is safe but perhaps going too far. There's nothing wrong with citing Pubmed articles. The question is which articles, and what statements you build from them. Colin°^Talk 10:29, 3 November 2006 (UTC)

In science, avoid citing the popular press

The popular press generally does not cover science well. Articles in newspapers and popular magazines generally lack the context to judge experimental results. They tend to overemphasize the certainty of any result, for instance presenting a new experimental medicine as the "discovery of the cure" of a disease. Also, newspapers and magazines frequently publish articles about scientific results before those results have been peer-reviewed or reproduced by other experimenters. They also tend not to report adequately on the methodology of scientific work, or the degree of experimental error. Thus, popular newspaper and magazine sources are generally not reliable sources for science and medicine articles.

What can a popular-press article on scientific research provide? Often, the most useful thing is the name of the head researcher involved in a project, and the name of his or her institution. For instance, a newspaper article quoting Joe Smith of the Woods Hole Oceanographic Institution regarding whales' response to sonar gives you a strong suggestion of where to go to find more: look up his work on the subject. Rather than citing the newspaper article, cite his published papers.

Which science journals are reputable?

One method to determine which journals are held in high esteem by scientists is to look at impact factor ratings, which track how many times a given journal is cited by articles in other publications. Be aware, however, that these impact factors are not necessarily valid for all academic fields and specialties.

In general, journals published by prominent scientific societies are of better quality than those produced by commercial publishers. The American Association for the Advancement of Science's journal Science is among the most highly regarded; the journals Nature and Cell are notable non-society publications.

— WP:RS

Popping over from WP:RS - I took a look at the cites in question and have no doubts that they meet the criteria for reliablility. I will leave the issues of Original Research and POV to others. Blueboar 13:28, 3 November 2006 (UTC)

My two cents: Cite the study, but cite it properly. Don't imply that it shows real disadvantages and side-effects. State what the study did. Make it clear that the study was performed on mice. This isn't the place for analysis. Just state the facts and make readers judge for themselves. Fagstein 05:20, 7 November 2006 (UTC)

neurodegeneration

i think, though, that anon has a point about fibromyalgia--i can't remember if i put that in because it was in the full text of the article (which i don't have access to right now) or if i did that because it is the only neurodegenerative disease complained about by depo users. since the citations for the depo users who complain of fibromyalgia are messageboards/blogs and hence not WP:V sources, it is probably better to stick to wording of citation--i didn't do that because 1) wikilink to "neurodegeneration" is a really uniformative stub 2) i think it sounds scarier than fibromyalgia. but, standard is verifiability, not truth, so neurodegeneration it is. i dunno, if fibromyalgia sufferers who used depo are then upset--a fibromyalgia controversy section could be added--they are reliable sources on themselves/that's the only circumstance under which they are RS. Cindery 02:41, 3 November 2006 (UTC)

removal of WHO stat

this is the direct quote, from page 2. I will be restoring cited material deleted by anon.

"The WHO solicits tens of millions of dollars yearly from companies whose fortunes it directly affects. In fact, the international agency now takes in more private money — more than $500 million a year — than it gets in dues from its 192 member nations." Cindery 02:55, 3 November 2006 (UTC)

But the name of this article is Depo Provera. The cited source doesn't mention depo either. I think I agree that this info is off topic, but I'm totally willing (as always) to hear counter arguments.--Andrew c 03:18, 3 November 2006 (UTC)

Cited source is all about depo--MPA is an abbreviation of Depo's name "medroxyprogesterone acetate." Cindery 03:21, 3 November 2006 (UTC)

... i made this separate section--"removal of WHO stat" to indicate new topic--an anon last week or so deleted the WHO stat from "controversy over approval of depo."--totally unrelated issue. sorry for any confusion 'bout that. Cindery 03:24, 3 November 2006 (UTC)

Removed the following false and misleading statement and reference:

The WHO now receives more funding from drug companies than from its 192 member nations.[8]

The WHO does not now receive more funding from drug companies than from its 192 member nations. See Talk:World Health Organization - Funding controversy.

69.208.178.182 05:42, 3 November 2006 (UTC)

You appear to be unclear on a couple key concepts/Wiki policies:

1. it is not sufficient justification to remove cited content by saying "see talkpage" of another article.

2. the citations you have provided on the talkpage of the other article are both 1)press releases/position papers published by WHO 2) pre-date the cited source you have removed twice from this article.

3. It is not helpful or harmonious editing to put "remove false and misleading content" as your only justification for deleting cited content, esp. if you make no discussion on the talkpage, don't cite sources, etc.

If you can find a cited source from 2006 re the WHO's budget that contradicts the Seattle Times article stat, even if is WHO, (which would have to be noted as the source) the Seattle Times stat could have a counterpoint. "One source says x about y, y counters that z is the case." Cited content from a reliable source cannot be removed--especially from a "controversy" section--because the subject criticized therein claims it is not the case... Cindery 06:43, 3 November 2006 (UTC)

First of all, I repeate what I said. This article is extremely problematic. It does not mention Depo, MPA, or anything having to do with this topic. Secondly, it says ONE thing about the WHO The Times found that ... Pharmaceutical firms have commandeered the process by which diseases are defined. Many decision makers at the World Health Organization, the U.S. National Institutes of Health and some of America's most prestigious medical societies take money from the drug companies and then promote the industry's agenda. This, from a popular media source. How does that one sentence suggest The WHO now receives more funding from drug companies than from its 192 member nations. I think you have your citations mixed up. Or maybe I am missing something (and I apologize if I have). But the cited source does NOT verify the content included in this article, and I stand by my original concerns about it being off topic. --Andrew c 15:29, 3 November 2006 (UTC)

That particular page doesn't mention the relevant quote, but if you click on Hypertension in the panel on the RHS, you get this page, which does. But I agree, it is off topic and is an ad hominem argument regarding the WHO rather than just this drug. It belongs elsewhere. Colin°^Talk 16:02, 3 November 2006 (UTC)

Thanks for the correct link. I'm guessing the appropriate quote is The WHO solicits tens of millions of dollars yearly from companies whose fortunes it directly affects. In fact, the international agency now takes in more private money — more than $500 million a year — than it gets in dues from its 192 member nations. Keep in mind our wording. We say that drug companies contribute more than the member nations. However, this is NOT what the citation is saying. It says, "tens of millions of dollars", not hundreds of millions of dollars, comes from we assume drug companies, and that private money, not necessarily drug money, makes up the $500 mil. I believe we are misrepresenting this quote. And yes, I agree that this inclusion is a red herring and off topic.--Andrew c 16:33, 3 November 2006 (UTC)

...at the top of this thread, i included the direct quote verbatim that you are "guessing" is the correct quote---(and the link to which it is verfifiable has always been there/been provided.)

the quote is included in a "controversy" section, specifically, it is a recounting of the history over the "controversy over the approval of Depo Provera," in which many inverstigative journalism cites are quoted--i.e., it is a section very much about the social and political issues surrounding the approval of Depo, and as such, must include sources such as investigative journalism citations. anon would need a citation that says "companies whose fortunes it directly affects"/private money isn't money from drug companies/from foundations/orgs that get drug company money to pass on---even his/her outdated WHO budget from 2001 notes that in that year, the largest single private donor to WHO was the drug company Merck--40 million dollars, and would still be making the point that the WHO has COIs to take under consideration viz its drug endorsements (which is also a point of the Seattle Times article, which explains in more detail WHO/COI/drug endorsement by the WHO as problemmatic for the public health.)

Moreover, the quote specifically says WHO "solicits" tens of millions--it gets more than 500 million. Happy, as i said, to include "counterpoint" citation if someone does research/ finds cite. (the "other side" is given re monkey study data here, and by me--it's the controversy section, hello.) Cited content someone objects to can't be removed from a controversy section--that would be where it would be moved to if it were NPOV to have it another section...the Seattle Times investigative journalism piece offers very useful information to the reader which helps explain why the WHO might have an increased stake in defending a drug/reworking an "analysis" of the drug based on studies previously rejected by the FDA. The WHO reworked an "analysis" of the same Thai data for Pfizer that what was previously submitted by Upjohn and rejected by the FDA for 20 some years--hence COIs/a change of funding sources of the WHO towards COIs is relevant. Last but not least, The WHO cite follows an FDA cite, which doesn't mention Depo either--it mentions that the FDA is more compromised institution than it was when Depo was rejected. Since the FDA and the WHO are clearly important subjects addressed in the "controversy section," cites which mention that the FDA/WHO are controversial orgs viz drug approval and endorsement don't just make sense, it gives the reader valuable citations to investigate further why the FDA would make a different assessment of the Thai data. (Did you read the transcript summary of the hearings in which the FDA rejected the Thai data later reworked by WHO for Pfizer--see above in this talkpage "disapppearing link.") Finally, it doesn't even actually matter how exactly/which wording is used in a quote from the Seattle Times investigative journalism 5-part series--the series makes the point at length that the WHO gets more private money than member-nation money/the WHO endorses drugs from drug companies who give money to the WHO. A tweak of the quote wouldn't change the criticism of the WHO regarding the drug endorsements it makes/the COIs it has in making drug endorsements, doing favorable studies for drugs. (If you read the ST article, that's clear.) This seems to me to be POV-pushing by anon--trying to remove cited content that is clearly relevant from a controversy section, by nitpicking re how the irrrefutable point that controversy exists regarding the WHOs funding/the WHO has been criticized for taking donations and then endorsing drugs by making favorable and misleading studies of them. Cindery 18:39, 3 November 2006 (UTC)

anon IPs all the same

Yes, it does appear that we have had this argument before, and that the same anon who objected to a source by calling her a "native american women's healthcare activist" is the anon who used the "inbred mice" edit summary, etc and has deleted cited WHO content, and would prefer to delete citations from disadvantages section-- so far, I have that the following anon IPs are the same: 68.253.177.143/ 68.255.20.88/ 68.253.189.62/ 69.208.178.182/ Cindery 08:47, 3 November 2006 (UTC)

= flag article's factual accuracy and NPOV as disputed

The majority of this article has been written by a single editor who persistently and blatantly violates WP:NPOV, WP:NOR, and restores inaccurate information, using Wikipedia as a soapbox to push their POV that Depo-Provera (and most other contraceptives) are dangerous products foisted on women by a conspiracy of greedy and malevolent corporations, public health organizations and physicians. 68.255.20.88 08:05, 3 November 2006 (UTC)

I have to say your comments are all pretty clear violations of WP:AGF, WP:CIVIL and WP:NPA It also seems that, under a number of IPs--perhaps not as intentional sockpuppetry, but because you are randomly assigned different IP numbers? --you have consistently been violating WP:CIVIL for a while now in all of your edits and edit summaries (but that you have consistently been treated with courtesy nontheless).

Certainly if I have "consistently" breached NPOV, you would have brought it up before? Please describe. Also please enlighten us regarding what is factually inaccurate in article. If your only argument is an ad hominem attack against me, you have misused tags. Thanks, Cindery 09:21, 3 November 2006 (UTC)

comment from SlimVirgin

Hi Andrew, first of all, the article is not about "Depo Provera use in humans"; it is about the drug in general, and so any information about the drug that is published by a reliable source may be used. Even if it is a study with a minority conclusion, it may still be used. However, it should not be used to draw conclusions that the study itself did not draw. It should simply be described, sticking closely to what the authors of the study said, and going no further. SlimVirgin (talk) 03:41, 3 November 2006 (UTC)

Thanks for the imput. When writing up my summary request for comment, I was thinking that would be a good solution. Don't drawn new conclusions from the study, or make it seem as if the results fit under a category they don't, but instead relay them in a manner that is representative of the study in question (this fixes the OR and RS concerns, but still, there are questions about notability and NPOV). --Andrew c 15:24, 3 November 2006 (UTC)

She doesn't say that the one sentence study summaries exist a category in which they shouldn't. Also, please see your own comments regarding the herpes rat study--i.e., the ones in which you agreed with both category and summary...

What she does do I think is make the excellent point that an article doesn't have to be a rehash/mirror of a drug product insert or a textbook, nor should it be.

I think it would also be a good idea for you to actually read the studies re Depo and STDS--the first cite in disadvantages re Depo/STDs was not added by me, but linked to the others (Depo appears to suppress immunity in general, making users more susceptible to pretty much all of them...) Cindery 19:08, 3 November 2006 (UTC)

Wording of our sources

Our source (which is summarizing a primary source) says While clear links between HIV transmission and Depo-Provera use have not been established, preliminary studies on female rhesus monkeys receiving progesterone (the main hormone in Depo-Provera) found them eight times more likely to contract SIV (a monkey version of AIDS) than a group not given progesterone. In these studies, it appeared that the progesterone significantly thinned vaginal linings and made it easier for SIV to enter the body. We say Depo Provera may enhance HIV transmission.

Our source says Mice immunized with an attenuated strain of HSV-2 2 weeks after Depo-provera treatment failed to develop protection when challenged intravaginally with wild-type HSV-2. In contrast, mice given progesterone and immunized at diestrus or estrus were completely protected from intravaginal challenge. These studies show that Depo-provera treatment changes susceptibility and local immune responses to genital HSV-2 infection. Animal models and vaccine strategies for sexually transmitted diseases need to consider the effect of hormone treatments on susceptibility and immune responses. We say Depo Provera may simultaneously increase susceptibility to the herpesvirus and decrease immune response to the herpesvirus.

I think the placement and wording is problematic. These points are listed under Disadvantages & side effects. The majority of the points in this section deal with human studies, and say as much women under 35, Fifty percent of women, and Infants born to women. The more less establish points are qualified as A study of 819 women in one city and in one study. I think there is a seperation being created that is subtly misleading. I would at the very least change the wording to say something along the lines of One study linked rhesus monkeys with progesterone implants (similar to, but not identical to depo) to an eightfold increase in SIV contraction. or A study in mice found that those treated with depo were more susceptible to HSV infection, and had decreased local immune responses to the virus.

And this brings up another issue, the SIV study doesn't even deal with depo. It delt with progesterone. The HSV study says progesterone works were depo doesn't. Is the SIV study even relevent? It's only supported by a secondary source. We've removed cited secondary sources in other articles (remember the pill that prevents cancer news articles?)--Andrew c 19:44, 3 November 2006 (UTC)

Perhaps it would be helpful for you to read this: [9]. (It is true that reading secondary sources can be helpful for understanding some med/sci issues--evaluating the secondary source is important--is it a rehashed press release like the pill/cancer article, or is it balanced news report? etc. I still prefer to cite pubmed, but maybe this will make things simpler for you viz understanding issues...)

• note: I suppose this '96 article is only useful in helping you understand issues at play if you know that all the synthetic progestins do thin vaginal walls and thin the endometrium as well--that's one of their primary contraceptive mechanisms of action.

Re herpes study--the conclusion re Depo is that it did two things: increased susceptibility and decreased immune response. You could argue that the conclusion--"influence of hormones must be considered in vaccines" is the conclusion of the study--and that, i think, would be nitpicking which does no service to readers--the clear conclusion that pertains to Depo is relevant to the Depo article...(i.e, what they found about Depo and reported was the by-product of a study re hormones and vaccines, but the fact that the study did not begin as study of Depo/herpes does not render the finding re Depo not relevant--this is how many scientific discoveries are made--go looking for one thing and find another...) Cindery 20:57, 3 November 2006 (UTC)

I'm sorry for the confusion. I agree completely that a study on depo (even in rats) is completely relevent here. My concern was the way it was worded, and the way it was simply listed along side the bone loss warning. My solution to this problem was to slightly reword to explain it was only one study in rats, and to create a section seperate from the known, listed warnings, that cover other cited, verifiable, and reliable studies (that either need more study, or are not significant enough to be listed as warnings and precautions on the drug label). I hope we can agree on this solution. I also added the warning listed between cancer and bone density warnings on the label, menstrual disruption (temporarily forgetting it had its own section already in the article). I believe it fits better where it is now, so hopefully that move wasn't controversial. Sorry I went and solicited outside imput on this conflict. I have been avoiding conflict recently, and also felt that both parties had fairly good arguments supported by policy, that others could give a 3rd opinion on matters. I feel we worked out a good solution. We addressed anon's concerns that single studies on animals were being listed along side published, black box warnings for why the drug can be harmful. And we addressed (hopefully) your concerns about deleting cited, verifiable content.--Andrew c 22:48, 3 November 2006 (UTC)

related studies section

Excellent idea--good edit.

(I think the HIV research has more updates, but can be tweaked later) Cindery 22:32, 3 November 2006 (UTC)

Thank you :)--Andrew c 02:39, 4 November 2006 (UTC)

References and WHO

The references in the WHO paragraph seem off. There are 2 external links, and one foot note. One of the external links is dead, another one doesn't mention AGI (so maybe it is misplaced). I was wondering if anyone (probably Cindery) had the time to look those over and perhaps fix them up? I'd appreciate it. And maybe, as a compromise, add a short clause in the WHO section that desribes the critical comments regarding drug money from the Seattle times article. Something like "The WHO, whose objectivity has also been criticized for receiving donations from pharmaceutical companies,..."--Andrew c 22:56, 3 November 2006 (UTC)

Breast cancer risk

I've removed the blanket statement that Depo increases breast cancer risk. There are multiple major problems here. First is the cited source. It's from the "popular press" and clearly has a partisan anti-Depo agenda. WP:RS cautions both against citing the popular press on scientific topics, and against using partisan sources if avoidable. The other issue is that the claim is contradicted by both the FDA and by the primary literature (e.g. PMID 15105056, a recent large study finding no significant evidence of an increased risk of breast cancer). So this provocative claim about Depo and breast cancer needs to be removed; these kind of claims should really be backed up by primary data, or at least something more reliable than the anti-Depo article that was the current citation. MastCell 23:39, 3 November 2006 (UTC)

I think you're right that the source should be moved to "controversy" section--the Canada part of it in specific, as the Vancouver Sun is a (RS) Canadian newspaper, and is referring to the controversy re Depo in Canada.

Re breast cancer risk, you are incorrect, below is Pfizer product info, (certainly a noncontroversial source) which cites risk is increased for one category--recent users (within last 4 years) under 35...

"...from two case-control studies, the World Health Organization Study and the New Zealand Study reported the relative risk (RR) of breast cancer for women who had ever used DEPO-PROVERA CI as 1.1 (95% confidence interval (CI) 0.97 to 1.4). Overall, there was no increase in risk with increasing duration of use of DEPO-PROVERA CI. The RR of breast cancer for women of all ages who had initiated use of DEPO-PROVERA CI within the previous 5 years was estimated to be 2.0 (95% CI 1.5 to 2.8). The World Health Organization Study a component of the pooled analysis described above, showed an increased RR of 2.19 (95% CI 1.23 to 3.89) of breast cancer associated with use of DEPO-PROVERA CI in women whose first exposure to drug was within the previous 4 years and who were under 35 years of age." Cindery 23:52, 3 November 2006 (UTC)

Could you please forward me the reference for the Pfizer product info you're citing? I'm looking at the product info on UpToDate and don't see what you're referencing. I also looked up the product info on Thomson's MicroMedex/DrugDex, and found the following:

a) In a follow-up study of postmenopausal breast cancer cases (n=2082), estrogen-progestin regimens increased breast cancer risk more than estrogen alone. The relative risk of breast cancer increased by 0.01 for each year of estrogen-only use and by 0.08 for each year of estrogen-progestin use in recent users, after adjustment for mammographic screening, age at menopause, body mass index, education and age. In lean women, the relative risk increased by 0.05 for each year of estrogen-only use and 0.11 for each year of estrogen-progestin-only use. In heavier women the risk did not increase with use of estrogen-only or estrogen- progestin only (Schairer et al, 2000).

b) A World Health Organization hospital-based case-control study involving 869 newly diagnosed breast cancer cases and 11,890 controls found no increased risk of breast cancer associated with ever use of depot medroxyprogesterone acetate for contraception (WHO, 1991). Relative risk did not increase with duration of use.

c) A multicenter trial involving 269 patients and 4501 controls indicated a relative risk of breast cancer induced by medroxyprogesterone as 0.7. This value was considered statistically insignificant. The lowest risk factor of 0.5 was observed in women who used medroxyprogesterone for 3 or more years. These data indicate no risk of breast cancer and a possible protective effect particularly with long-term users of medroxyprogesterone (Thomas et al, 1985). Another study involving 110 patients and 252 controls indicated a relative risk of 1. However, in women between 25- to 34-years-old who had used medroxyprogesterone for six years or longer the mean relative risk was 2. Contrary to the first study, these data indicate an increased risk of breast cancer in young women administered medroxyprogesterone (Paul et al, 1989).

d) No increased risk for the development of cancer of the breast, uterine corpus, and ovary was reported in 5000 black women who received medroxyprogesterone injections for conception between 1967 and 1976 (Liang et al, 1983).

e) No increased risk of breast cancer associated with the use of depo-medroxyprogesterone acetate in 11,400 women was found (Greenspan et al, 1980).

Which mentions the one finding of increased risk in young folks but presents a balance of evidence that there is no increased risk. I must be missing the source you're citing - could you forward it? Thanks. MastCell 00:45, 4 November 2006 (UTC)

This is the most up-to-date product insert, dated "revised 2006." [10] Cindery 03:22, 4 November 2006 (UTC)

Bone mineral density

I've tried to beef up the references for the section on the black box warning and bone mineral density. It appears there was some feeling that Lacroix (2nd author on the studies?) had a significant conflict of interest, and that this conflict was relevant because there were said to be no other studies replicating her findings. So I added a second study reaching a similar conclusion, by a different set of authors. Nonetheless, I tried to bring it back to emphasize that the ultimate risks of fracture are unknown, but significant enough that Pfizer and the FDA placed the warning and don't recommend using Depo for >2 years. MastCell 00:25, 4 November 2006 (UTC)

Thanks--since the New Zealand study was supertiny, and concluded loss is irreversibale in long-term users, I have noted that. And since it was so small and came to a diff conclusion than LsCroix, Pfizer COI for LaCroix still relevant (the LaCroix studies were just one study, out of which they got two papers..) Cindery 00:40, 4 November 2006 (UTC)

You're right about the NZ study - I added the part about long-term users not recovering BMD. However, about Scholes/Lacroix, the relevant studies were submitted, approved and funded entirely by the National Institutes of Health. Pfizer had no hand in designing or funding them, nor do they include any conflict-of-interest statements. Using a different study, which was funded by Pfizer, to imply a conflict of interest in this government-funded study is WP:OR, unless you can cite someone making a similar connection outside of Wikipedia. MastCell 01:11, 4 November 2006 (UTC)

The statement made is not that Pfizer funded the study, but that LaCroix is a consultant for Pfizer (and the citation provided clearly states that LaCroix is a Pfizer consultant).

(Have you read the prior talkpage discussion on this, where the NIH funding is clearly noted, etc)?

As an aside, the spirit of "OR" (and we are supposed to follow the spirit, not the letter of policy, as "Wikipedia is not a Bureaucracy") is to prevent publication of crackpot original theories, avoid primary sources which are privacy vios, etc. etc. (All too often, "OR" is instead invoked as a technicality someone would like to use to delete cited content they object to, in an abuse-of-process which uses arguments far more "original" and creative than whatever tedious mundane detail is under objection. :-) But I will AGF that that's not what you're doing/have any intention of doing.)

Cindery 01:39, 4 November 2006 (UTC)

The spirit of WP:OR is to present data neutrally and avoid having us (the editors) insert our 2 cents about how valid a study is, how it should be interpreted, whether it's biased, etc. Using an unrelated article to suggest that a conflict of interest exists, when none was reported in the article in question, is the definition of OR. If no conflict of interest was reported by the peer-reviewed journal in question, and you can't find an outside source making the insinuation, then it's OR. "Crackpot theories" are in the eye of the beholder. Some would consider the suggestion that the NIH, WHO, and University of Washington are massaging data to push Depo-Provera a "crackpot theory", and it's definitely OR unless you can show me a conflict-of-interest statement for the article in question, or a source alleging a conflict of interest. Am I taking crazy pills here? Does anyone else have an opinion? I'd really welcome a 3rd or 4th opinion here. MastCell 05:41, 4 November 2006 (UTC)

There was a source listing LaCroix as a Pfizer consultant, cited in the article--I will check to make sure that through your revisions, it wasn't somehow deleted. (See discussion section on this talkpage, #15, titled "LaCroix.")

Using an unrelated article to suggest that a conflict of interest exists --This makes it appear that you have seen source I cited for Lacroix's COI, and are semantically hung up on the difference between "being a Pfizer consultant" and "receiving money for a specific study"--she's a Pfizer consultant. That means, at all times, she has a financial COI viz Pfizer. It's not a suggestion--it's a cited fact: she has an ongoing financial COI. Zero interpretation is given of this COI--that would be OR/editorializing, etc.

There is a specific injunction in WP:RS, under the specific advice for sci/med/math, to Physical sciences, mathematics and medicine, to "Make readers aware of any uncertainty or controversy." Especially given that the Lacroix results have not been reproduced/there is so little info to cite regarding "reversability" of BMD loss with Depo, (esp. regarding teens and BMD accretion in crucial growth period) it would do a disservice to readers re WP:RS not to include the COI--it's an acutely relevant element of "uncertainty and controversy" regarding the reliability of a source, which readers should be able to take into account when they evaluate the information given. Cindery 07:05, 4 November 2006 (UTC)

The articles in question mention no conflicts of interest. Joining source A (the Depo articles) with source B (an unrelated article in which 1 author claims a COI) to advance position C (that a COI exists for the Depo articles) is the definition of OR. The journal which published the Depo articles lists no conflict of interest. If you want to hunt for a paper trail and make the allegation that an undisclosed COI exists for those articles, based on a COI notice in an unrelated article, more power to you. I'm a big fan of investigative journalism, but it is totally inappropriate for Wikipeida. Cite a source making the connection, or it's OR. The argument about needing to emphasize the "uncertainy and controversy" is also inapplicable. We emphasize the uncertainty directly in the text ("...no study has directly examined fracture risk in post-menopausal women who have used Depo-Provera; therefore, the risk is unknown. Pfizer and the FDA recommend that Depo-Provera not be used for longer than 2 years, unless there is no viable alternative method of contraception, due to concerns over bone loss"), not by making OR insinuations about the 2nd author's COI's. I'm not going to say more until I hear from some of the other regular contributors to this page, because I'd like some outside opinions on this. MastCell 16:25, 4 November 2006 (UTC)

breast cancer

I have to say it's not really appropriate for an experienced editor to delete content for which citations have been provided on talkpage (meaning, there will presumably be ongoing discussion over whether to cite product insert, or the studies therein, etc). Even if you had an objection to the way the source was temporarily cited, I believe you aware that the appropriate thing to do is insert , and continue ongoing discussion on talkpage--bad faith to delete content on "technicality" when you are aware there is cite/are multiple cites...(and aren't you up to 2RR on this and Pfizer/LaCroix in less than two hours, shortly after arguing with me on EC talkpage, and never having editing this article before???) Cindery 02:44, 4 November 2006 (UTC)

Thank you for the accusation of bad faith. Please read WP:CITE. Regarding unsourced assertions, it states that "If it is doubtful and harmful, you should remove it from the article." Claiming a link to breast cancer without a citation is harmful. Putting (Pfizer) in parentheses is not a citation. The appropriate link is to the package insert you forwarded above. You still haven't put this in the article, so I'll do it. But at the time you (re-)inserted the claim, I could find no source, you had provided none, the claim is potentially harmful, and as the person inserting the claim it's incumbent upon you to source it properly. I'm sorry I'm a newcomer, but there are no seniority benefits here. As a separate issue, to be an accurate representation of your source, you might want to quote the lead sentence on breast cancer risk, which states that long-term studies have found no overall increased risk of breast cancer with DEPO, along with the subsection on subgroup analysis. MastCell 05:33, 4 November 2006 (UTC)

Ok...let's start with the misunderstanding re "newcomer," and hopefully that will go a long way towards reducing animus, and we can work our way back to cooperation 'n' harmony: I wasn't accusing you of being a newcomer, I was accusing you of being an experienced editor! When I said, "as an experienced editor..." I was referring to you/saying "I know you know better." You and I began contributing to Wikipedia within a week of each other--I don't consider myself a new editor, and so I didn't think of you as one, either. But, for any confusion or misuderstanding or assumption of bad faith, I sincerely apologize. Maybe I've made more edits than you/feel like less of newcomer--that doesn't matter. You are correct that there is no seniority, and it is also important not to bite the newcomers.

You might want to read over the rules about reverting, though, since you're still somewhat new/think of yourself as new--it's preferable only to revert once. Even if you think "this is doubtful and harmful!"--unless it is defamtory content about a living person or blatant vandalism, you should not revert repeatedly on that argument while a talkpage discussion is in progress about an edit (and especially not if you are aware there is a citation, but it has not been formatted properly yet--as I said, in that case put , if you think it is necessary. "Citation needed" is generally left up for quite a while--it's considered rude to hastily delete "Citation Needed" without giving other editors time to provide citations. They are generally left up too long, like for a month or two. But they are certainly not deleted in a day or two (let alone minutes).

I think I am also guilty, since I noticed you are a doctor, of assuming that you had some knowledge already of the breast cancer stats re hormones, the big WHO epidemiological study etc. For that, I also apologize.

Lastly, to address your point about "no risk overall"--the info re younger than 35/use within last four years is in the disadvantages section, where it belongs, as that is the disadvantage to Depo re breast cancer. Cindery 07:29, 4 November 2006 (UTC)

Since you've studied my edit history, you perhaps realize that engaging in edit wars or revert-a-thons is not my style at all. However, you may have also noticed that I feel strongly about citing sources, especially on medical articles. I don't revert claims that have a reliable citation. However, I will remove any potentially harmful, unsourced claims in accordance with WP:CITE. You need to add a citation for such edits at the same time as the claim. Period. It's considered rude to put provocative, unsourced claims in an article and then attack editors who request that you supply a source. I'd suggest you review the citation process and policy since you continue to think I was being unreasonable. I'll ignore your more condescending comments, as you seem to be trying to push my buttons, and repeat that the issue is not my familiarity with the relevant studies, or my insecurity about how long I've been editing. The issue is simple: you need to cite sources. Otherwise your edit risks being removed until you include the citation. I'm quite familiar with the data on Depo and breast cancer, but my personal knowledge (or yours) doesn't obviate the simple fact that an adequate citation is required. This is not me being a renegade; this is Wikipedia policy. If you spent the same amount of time sourcing your edits as you do accusing me of bad faith, rudeness, "2RR", and personal attacks, this discussion would be unnecessary. MastCell 16:05, 4 November 2006 (UTC)

...I haven't looked at your edit history at all, except to check when your first edit was after you said you were a newcomer. When I saw you started this August, it didn't seem improbable to me that maybe I was "biting" a newcomer, so I apologized. Cindery 16:27, 4 November 2006 (UTC)

---

Hi Cindery & MastCell. Mastcell asked if I could offer comment on this talk page. As such I have not looked at the various edit-history article differences in the last couple days, and having read the above discussion re Bone density and Breast cancer threads, I shall hold off looking at the article so that I can respond about the talk-page discussion itself. I have observations about each of your comments above, but please take this in the positive constructive manner I intend - I certainly don't mean to belittle either of you, cause upset, offence or any discouragement in your fine works at wikipedia :-)

1. Firstly MastCell (you invited the commentary, so only fair discuss your comments first). You stated to me that "I feel I'm getting more argumentative than I should". I think this is probably true, but on a positive note, at least you recognised this and sought a way out of a 1-on-1 argument, which is usually the best approach here in wikipedia. As a start, I would suggest an acknowledgement (apologise if you wish) to Cindery for being "more argumentative than I should" - it never hurts to be humble, especially in an impersonal electronic medium (think of the use of smilies) :-) Whilst it is easy to inadvertently escalate a discussion, it is hard to cool it down. If you have a look at WP:Civility "Please. Thank you. I'm sorry. You're welcome" are encouraged. As a suggestion, talk about a point or issue, not the other editor. As an example, you posted above "You need to add a citation for such edits at the same time as the claim. Period.", putting aside what the information in the citation did or did not support, your edit would have been better written as: "The phrase at the same time as the claim would seem to need its own citation to support the inference and linkage of issues" - doesn't that convey what you seek for the article in a less confrontation manner? Whether Cindery was right or wrong about the interpretation of a paper or two, stating "Period" was indeed "getting more argumentative" - you both joined wikipedia within a few days of each other and are both therefore familiar with all the policies/guidelines - there is no need to lecture each other.
2. Cindery, again welcome back to these topics you have so much knowledge over. I reflect the same issues over commenting on other editors vs. commenting on issues raised by other editors to you. You posting "I think I am also guilty, since I noticed you are a doctor, of assuming ... For that, I also apologise." I can only assume this reads differently from how you intended this to seem. Having offered a suggested alternative to MastCell posting, only even-handed to do likewise for this example. I think this would have been better inverted as commentary on your own depth of knowledge and offer to discuss in detail where another editor may need a pointer to the research, also never hurts in passing to compliment the other editor, hence:. "Although I am not a doctor, I have a particular interest in this topic and have spent considerable time researching the various studies as well as looking into the background of these studies. I appreciate as a doctor you will have knowledge across a broader scope of medicine and the wisdom that this brings. Would it be helpful therefore for us to discuss the issue of breast cancer stats re hormones as this applies to several wikipages – we can then work better together on this aspect of hormonal contraceptives." Hmmm that was very very verbose, and I know Cindery you have better prose skills than me.
3. To the both of you I would remind that wikipedia is not a soapbox and any issue must be quotable from the real world, and this also applies to the significance of any issue.
   • So if "Depo-Provera causes a significant problem of X", then one needs to find one or more citation to support that it can cause X and also that this is a significant problem (the latter is far more subjective than the first is objective).
   • Generally one citation for a problem is not good evidence, as it suggests that it has neither been scientifically reproduced nor commented upon widely in the medical journals, medical media, or the wider media to support this as having been generally accepted by the medical/healthcare community. Now this may of course indicate that the medical community is being inflexible and closed to innovation or Evidence Based Medicine, but it is not wikipedia's job to comment on this (only if one can cite an external reliable source that makes that assertion).
   • Initial identification of a risk is probably better written in a more conservative fashion than not - later studies may well strengthen the original findings and wikipedia can always be later edited to strengthen comments, but until then the original paper is merely one point of view.
   • I would also point out that wikipedia is just (and what a "just") an encyclopaedia, it is not a medical textbook, nor testimony that would stand judicial review (remember its WP:Neutral point of view not Wikipedia:Scientific point of view). "Wikipedia is not an indiscriminate collection of items of information. That something is 100% true does not mean it is suitable for inclusion in Wikipedia"^{(WP:NOT#Wikipedia is not an indiscriminate collection of information)} Remember the target audience is expecting to read an encyclopaedic entry with summarised information, not expand debates, with article lengths generally below 32kb.

Again, I repeat, I have not looked into the actual page histories you debate above. Likewise you both are good editors - being knowledgeable in the topic, proficient in using wikipedia, aware of the policies, and having made some great contributions to various pages. So as a positive friendly suggestion (with quotes from WP:Civility), "use positive feedback", "force delays between answers", "balance each uncivil comment by providing a soothing or constructive comment", "treat your fellow editor as a respected and admired colleague" and feel a little regretful for the poor tone of the above two discussion threads. Take a day's wikibreak, re-read the various papers or their abstracts, see if any subsequent study or paper commented on them, and then working collaboratively treat the facts (not each other) as various points of view for which a NPOV description needs to be agreed upon.

I have no greater knowledge of breast cancer and hormones than that either of you, but may I suggest the style of inclusion and the quoting of external uncertainty over evidence, and the quoting of external opinion as to why that may be the case, with hormonal pills and breast cancer at Oral contraceptive#Side-effects - is that a style that might be applied over the points you discuss re bone density & breast cancer with Depo-Provera usage ? Hoping the above brings peace and tranquillity, and not fireworks this Guy Fawkes Night :-) David Ruben ^Talk 01:37, 5 November 2006 (UTC)